Cosmetic reshaping of the female breast is a collection of well known procedures such as implants and various forms of lifting and reduction. These breast procedures are so well accepted that it seems they have been around forever. But this is largely a cultural perception as what we know today or grew up with always seems like it has always been so.

While the history of aesthetic breast surgery is relatively short, it has been around now much longer than one realizes. Breast implants had their introduction now fifty years ago starting in 1968. But breast lifting and reduction dates back much longer, almost 100 years ago. While the surgical techniques may have started to develop then, the societal acceptance to actually do it was much different. This became very apparent to me in helping to create an english translation of the book entitled ‘ Deformities and Cosmetic Operations of the Female Breast’ originally written by Dr. Herman Beisenberger from Vienna Austria in 1930. In the first chapter of the book he writes the justification for female breast reshaping procedures.

‘Is cosmetic correction of the female breast deformed in some manner indicated even if no grave reasons propose it, if only the desire of thewoman or girl exists? As we are already been used to performing corrections of other regions of the body upon desire of the patient for a considerable period of time, we should not make an exception if mammaplasty is concerned, although we have to admit that the correction of the female breast, regardless if we deal with ptosis or hypertrophy of the breast, is always a major surgical procedure, which should be reserved for the hand of the experienced surgeon. We correct a hallux valgus of only moderate degree without reservation even if it causes no complaints but represents only a minimal malformation of the foot of its owner. We move protruding ears operatively closer to the head to satisfy a long standing desire of their bearer, who imagines appearing ridiculous because of his ears. We remove supernumerary digits of the hand of a child if desired by the parents as well as a vascular or pigmented nevus of the cheek; we correct the saddle nose or humps and all other deformities of this organ to protect its bearer from being conspicuous and free him from often only imagined ridicule; the overhanging panniculus is removed operatively; bents in legs not impairing ambulation in any way but regarded as unaesthetic experience surgical correction. We could add further to this examples of correcting deformities of the human body only because of patient desires. We also should not overlook that the wish to correct even a minimal malformation of a body part may, if constantly rejected, eventually result in depressive symptoms and maybe even in a feeling of physical inferiority. The refusal to alleviate a fault in the body’s appearance can therefore under very special circumstances result in the end in pathologic processes, which have to be taken seriously and necessitate treatment by a psychiatrist.Based on these considerations and taking into account the consequences alluded to, which could result, we will neither discount a priori the justification of the desire to have breast correction nor reject a well founded wish. The already large number of successful mammaplasties proves that surgeons have been acting along the above lines for a couple of years and additional testimony is provided in particular by respected authors such as Lexer, Kraske, Holländer, Axhausen and others preoccupying themselves with operative breast corrections and describing new operative methods or improvements of existing ones verbally and pictorially. Eiselsberg expressed this attitude regarding breast correction as well in 1928 when he performed such an operation as a demonstration for foreign guests giving the following introductory statement:

If I had been approached ten years ago to operate on a

ptotic breast for merely cosmetic reasons I would have

refused. You see, we have gone with the times, have

changed our point of view to take into account the wishes

of the public but without undiscerningly and uninhibitedly

accommodating arbitrary desire.

As can be seen from these very flowery but passionate writings from Dr. Beisenberger way back in 1930, reshaping a breast has an important psychological effect on a woman’s body image. It is not a recent phennomenon that has been merely promoted by contemporary fashion and beauty standards. The issue today is not whether it is morally appropriate for a plastic surgeon to perform a breast lift but whether the patients can accept the scars to do so.

Dr. Barry Eppley

Indianapolis, Indiana

Breast reshaping for many women requires a combination of volume enhancement/restoration and lifting of sagging skin and a low nipple-areolar position. Saline or silicone breast implants are placed in a complete or partial submuscular position and various types of lifts are performed on the overlying breast skin envelope. In most cases of significant breast reshaping, a vertical (lollipop) or combined vertical-horizontal (anchor) pattern of lifting is needed.

The following postoperative instructions for breast lifting with implants are as follows:

1.  Most of the discomfort after surgery is related to the submuscular implants and not the breast lifts. Pain medications are prescribed and most patients will need them. You should take them as directed on the label, usually 2 tablets every 3 to 4 hours as needed. After a few days many patients only use Tylenol or Ibuprofen. You may also feel free to use ice packs on your breasts for pain as long as they do not directly contact the breast skin.

2.  You will come out of surgery in a bra with gauze inside of it over the taped incisions. The bra is there for support and comfort. You may develop some spotting of blood onto the outer aspect of the bra the first night after surgery. This is normal and you need not be concerned.

3. You may remove the bra and the gauze inside it and shower 24 to 48 hours after surgery. It is ok to get the tapes wet. They are there to protect the incisions and eliminate the need for any wound care from your standpoint.

4. All breast lift incisions are closed with resorbable sutures under the skin. They are covered with glued on tapes for a week after surgery. Do not remove them. Dr. Eppley will take them off. It is also ok to have them get wet when you shower. Some spotting of blood may appear on the tapes and this is normal.

5. In rare instances, drains may be used after surgery. If so, empty them as needed. You will be given directions how to do so before going home after surgery. They may get wet in the shower. They will be removed in one to two days after surgery in the office.

6. Strenuous physical activities and working out should wait for at least two to three weeks after surgery. You do not want to put undue stress on the healing breast incisions. When you feel more comfortable you may begin working out by walking on a treadmill or on a stationary cycle.

7. You may eat and drink whatever you like right after surgery.  Focus on liquids and soft foods for the first few days after surgery.

8.   You may return to work and any non-strenuous physical activity as soon as you would like based on your comfort level.

9.   You may drive when you feel comfortable and can react normally and are off pain medication.

10. If any breast redness, increased tenderness, or drainage develops after the first week of surgery, call Dr. Eppley and have your pharmacy number ready.

Every plastic surgery procedure has numerous issues that every patient who is undergoing a procedure should know. These explanations are always on a consent form that you should read in detail before surgery. This consent form, while many perceive as strictly a legal protection for the doctor, is actually more intended to improve the understanding of combining breast lifts with implants. (also known as mastopexy augmentation breast reshaping procedures) The following is what Dr. Eppley discusses with his patients for these procedures. This list includes many, but not all,of the different outcomes from surgery. It should generate both a better understanding of the procedure and should answer any remaining questions that one would have.

ALTERNATIVES

Alternatives could include using a breast implant by itself or doing only a breast lift without augmentation. Each of these choices have their own consequences for the resultant breast shape which would not be the same as a combined breast lift with a breast implant.

GOALS

The goal of combination breast lifting with implants is to give the breast more fullness (particularly in the upper pole) and lift a sagging breast to a better position on the chest wall. In addition, the nipple-areolar complex is moved upward to a more central position on the breast mound.

LIMITATIONS

The limitations of breast lifting with implants are those of the final breast size achieved and how much lifting of the sagging breast can be done on top of an expanded breast mound. How much excessive breast skin one has, the remaining amount of underlying breast tissue, the elasticity of the breast skin, the amount of breast sagging and the size and droop of the nipple-areolar complex all pose limitations on the final result that can be achieved.

EXPECTED OUTCOME

Expected outcomes include the following: temporary swelling and bruising of the breast mounds and nipples, breast skin numbness, nipple numbness, permanent breast scars and weeks to months for full scar healing to occur. The initial shape of the breast mounds may look too high, too full or non-round. It may take as long as six months to see the final shape and size of the breasts as both the implants and lifts settle. Scars may take up to one year to fully mature.

RISKS

Significant complications from combined breast lifting with implants are rare but could include implant infection or partial or complete loss of the nipple-areolar complex. More likely occurrences could include delayed incisional healing with some separation and suture reactions, breast implant malposition or asymmetry, breast mound or nipple-areolar asymmetry,  recurrent breast tissue sag over the implants, scar widening and no guarantee can be made as to the eventual breast cup size. It is important to understand that the combined breast lift with implants is the most technically challenging of all aesthetic breast reshaping procedures and has a high risk of the need for revisional surgery for optimal results. Any of these risks may require revisional surgery for improvement.

ADDITIONAL SURGERY

Should additional surgery be required to do additional breast lifting, reposition and/or replace the breast implants or perform any scar revisions, these will generate additional costs.

Background: The combination of pregnancies, weight loss and gravity change most every woman’s breasts.All of these undesired changes are classic, the breasts change shape and they sag downward. The combination of more skin and less volume allows the breasts to lose their once uplifted and rounder appearance. Some women undergo involution only (breast tissue shrinkage)and develop no sag but this is not common.

The sagging breast may be able to be improved by implant augmentation alone but that depends on the degree of sagging. Only the most minimal of sagging can be improved by expanding the breast volume. If this is tried in more significant sagging, it not only is not improved but may actually become worse. For this reason, lifts need to be considered in many cases of breast reshaping regardless of whether implants are used or not.

Breast lifting can be accomplished by different types of lifts which are fundamentally differentiated by how much lifting they do and the length of scar they create. With the exception of the most minor degrees of sagging, only two types of breasts lifts really make a significant change. They are the vertical (lollipop) and combined vertical-horizontal (anchor) breast lifts which are so named based on their resultant scar patterns. Their degrees of lifting are impacted by the use of an implant and its size.

Case Study: This 45 year-old female wanted an improved breast shape after having children and losing a little weight. She has some mild breast asymmetry with one breast having some more sag and less volume than the other. More relevantly, the location of her nipples was slightly below the level of the inframammary folds on both breasts. While her initial request was for breast implants, it was pointed out to her that this would not produce the results she was hoping to achieve.

Under general anesthesia, a lower breast fold incision was made and an implant sizer (450cc) placed in a partial submuscular position. A vertical ellipitical skin pattern was then de-epitheliazed and the existing areolar size maintained. The nipple-areolar complex was then raised to the top of the lift excision and the breast skin tailor-tacked around it. Additional vertical breast skin was then removed and the vertical incisions closed after also removing extra skin around the areola to make sure it was circular and not distorted. in shape. All incisions were taped and she was placed in a bra. No drains were used.

Her tapes were removed one week after surgery and she returned to all normal activities two weeks later. She developed a few spitting sutures at one month after surgery which were removed. She went on to heal uneventfully. When seen at four months her breasts had a good shape with a near central nipple-areolar position. Her scars will take up to a year after surgery to fully mature.

While the breast lift implant combination procedure is needed for many deflated and sagging breasts, it is not an easy operation in which to achieve optimal breast shape, symmetry and a centralized nipple position on the newly created mound. There are many challenges to achieving what most women expect to occur without incident. In reality, this breast reshaping operation has a high rate of the need for revisional surgery to correct implant position or size, the amount of lifting and tightening, a good areolar shape, or revision of wide scars. This patient was able to achieve her breast goals in a single procedure which is fortunate for her although not always common.

Case Highlights:

1) Breasts that have lost volume and sag after pregnancy need a combination of volume augmentation and a lift.

2) The placement of implants with a concurrent vertical lift (lollipop) provide adequate reshaping when the amounkt of breast sagging is mild to moderate. (nipple at or just below the lower breast fold)

3) Breast lifts with implants has a higher need for revisional surgery than when either procedure is performed alone.

Dr. Barry Eppley

Indianapolis, Indiana

The placement of a breast implant is often viewed as being either under the pectoralis muscle or above it. When it comes to being above the muscle in the so-called subglandular position it can only be completely in that position. But when it comes to the submuscular position, a partial or complete placement relative to the muscle border is possible. This partial submuscular implant location is known as the dual-plane in which the bottom half of the implant is located below the muscle in the subglandular plane.

By placing an implant in two simultaneous tissue planes, the lower half of the breast tissue is expanded. This could be very useful in women that present for breast augmentation that have a mild degree of sagging. Breast sagging, known as ptosis, is a frequent confounding factor in breast augmentation. Contrary to popular perception, a breast implant has a very limited breast lifting capability. Only when the nipple is above the level of the inframammary fold can the plastic surgeon be assured that the nipple will end up in the center of the newly enlarged breast mound. But when the nipple is at or lower than the fold, some form of a breast lift will always be needed if the nipple is to be centered on the mound.

In these mildly sagging breasts is where the dual-plane implant placement approach is useful. One way to get the nipple centered, without a breast lift, is to lower the inframammary fold and increase the volume of the breast below the position of the nipple. To do so, the implant clearly  has to have a portion of it that is below the lower border of the pectoralis muscle.

In the January 2013 issue of the Aesthetic Surgery Journal, a clinical study on the dual-plane approach to breast augmentation in women with mild degrees of sagging was published. Over a period of eight years, a total of near 2000 women who underwent primary breast augmentation with either saline or silicone breast implants was evaluated. Of this group 256 patients underwent a dual-plane approach due to their existing breast ptosis. Their findings show that the dual-plane breast augmentation approach is best used for those patients that have minimal ptosis. In other words, those women that fall into the gray area of whether they should have a traditional breast implant approach or may need some form of a breast lift.

I have used the dual-plane approach for years and do find it to be useful when placing breast implants in women with mild ptosis/ (nipple at the level of the inframmary fold) One other technique that can accompany the dual-plane approach in these patients is to also do a simultaneous nipple lift. (superior crescent lift) This is a great way to hedge your bet so to speak to get the nipple as high up on the breast mound as possible. This combination will work most of the time to avoid breast lift scars in these ‘tweener’ patients.

Dr. Barry Eppley

Indianapolis, Indiana

Lifting of the sagging breast is one of the most challenging of all body contouring procedures. While measurements and angles are marked out for a breast lift, there is real artistry in choosing the design of the operation and executing it so that optimal symmetry exists between the breasts. Since every woman’s breasts are so different, often even in the same patient, this adds to the difficulties in achieving an optimally uplifted and fully shaped result.

For many women who desire fuller and more perky breasts, a lift is a necessity. While no patient likes scars, all lifts cause differing amounts of them that serve as the trade-off for better shaped breasts. But along with the certainty of scars comes the uncertainty of other important issues that should factor into each woman’s decision to have a breast lift. Many of these considerations are often poorly understood or are simply myths. Here are several of the most common breast lift myths.

A breast lift will make the breasts permanently lifted and perky. While a breast lift makes an immediate and often dramatic change in the position and shape of the breasts, the result will age just like any other part of the body. While a lift initially moves up a lot of the breast volume to behind the nipple and above it into the upper half of the breast, gravity and tissue relaxation will cause some of this tissue to move south over time. While few lift results ever return to where they once were, they are still subject to drooping in the future…it will just be from a different starting point than from where they originally were. How much recurrent dropping may occur  is affected by several factors. The simultaneous insertion of a breast implant helps prevent it. Pregnancy and weight loss will really exacerbate recurrent sagging.

The nipple is removed and put back on in a breast lift. There is no breast lifting procedure where the nipple is taken off and reapplied like a skin graft, thus permanently losing feeling and erectile capability. There are some breast reduction operations, now uncommonly done, where nipple grafting is used but never in a cosmetic breast lift. The nipple position is moved upward in a breast lift by keeping it attached to the underlying mound of breast tissue. It is the skin around it that is removed and tightened, pushing the breast mound upward and the nipple with it. This ensures normal feeling and function of the attached nipple.

Scars are needed to do all breast lifts. While this is a concept that I don’t like to counter, some women may get a  breast lift result from having implant augmentation alone. If the breast skin is in good shape and the sagging is minimal, some lift will occur with the push of underlying implants.  It all centers around how much sagging exists and where is the position of the nipple relative to the lower breast fold. If the nipple sits just above the fold or even on it, the nipple will be lifted up slightly. (maybe a half-inch) But don’t assume that if the nipple sags lower than the lower breast fold that really big implants will provide the push that is needed to create a lifting effect. In this situation, the implants will actually make the sagging look worse.

Despite the challenges that breast lift surgery poses, when carefully chosen and skillfully done, it can provide long-term breast shape improvement…and that is no myth.

Dr. Barry Eppley

Indianapolis, Indiana

Of the many women who present for consideration for a breast lift, the vast majority do not end up with a breast lift alone. While the various forms of breast lifting do successfully move the nipple position higher and tighten breast skin around it, it does not increase the size of the breast or in any way make it appear much fuller long-term. This is a surprise to most patients and, as a result, many breast lift patients opt to receive an implant as well.

The combination of an implant with a breast lift, known medically as an augmentation mastopexy, is far more common than a breast lift alone. But when you combine two different cosmetic procedures on a breast, even though the final result is better than either one alone, the technical difficulty of the procedure and the risks of complications also increases. While most of these potential combinations are aesthetic in nature, this does not make the potential need for a revisional surgery any more pleasant to the affected patient.

What is the risk of the need for revisional surgery in a breast augmentation mastopexy? In the January 2013 issue of Plastic and Reconstructive Surgery that very question is addressed in a paper entitled ‘Simultaneous Augmentation/Mastopexy: A Retrospective 5-Year Review of 332 Consecutive cases. In this paper, the authors do a retrospective review of 430 breast lift patients, 332 of whom had implants placed at the same time. The breast operations were 40% inverted-T, 40% vertical and 20% circumareolar (donut) lifts.  The breast implants used were 73% silicone and 27% saline-filled with 84% in a dual-plane submuscular pocket. This combined breast reshaping procedure had an overall complication rate of 23%. The most common reason for reoperation was capsular contracture, poor scarring and recurrent sagging.

This combination of concurrent breast reshaping procedures is challenging because the  two maneuvers are inherently diametric and somewhat work against each other. Increasing the volume of a breast and then lifting and tightening the breast skin around it is as much art as it is a scientifically measured technique. There is also the balance and intraoperative judgment of how much volume can be added and how much skin can be removed for the greatest lift without compromising the blood supply to the nipple-areolar complex.

Besides making the concurrent implant-lift operation work well on the operating table, there is the unknown and uncontrolled variables of the healing process. How much will the implants settle after surgery? Will the properties of one’s skin hold the lift up or will it bottom out? Will the scars stay narrow or widen? Will the breasts stay symmetric or settle unevenly? Will some degree of recurrent sagging occur over the implants?  Will the nipple-areolar complex widen over time.

When you factor in all the before and after surgery considerations for doing the combined breast implant and lift operation, potential patients need to understand that the risk of revisional surgery is anything but rare. Even by well-experienced plastic surgeons, as in this study, the revision rate was 25%.  I have always counseled these type of cosmetic breast patients that the risk was at least 33% and this study supports that contention.

Dr. Barry Eppley

Indianapolis, Indiana

Cosmetic breast surgery encompasses a wide array of procedures from the placement of implants, lifts, reductions, liposuction and fat grafting. This is not to mention another list of potential changes that can be done to the nipple-areolar complex with or without concomitant mound reshaping. But what makes breast reshaping surgery a very unique collection of procedures is that there are two paired breasts and they sit side by side. This makes comparing the surgical results of both breasts unavoidable.

Patients would like and expect near perfect symmetry in their breast surgery no matter how comparable (or not) that they were before. But the reality is that few breast surgeries result in ideal symmetry between the paired structures no matter how well executed the surgery is. Tissues mend, scars mature and breast skin relaxes differently as they heal. Even though the breasts are still next to each other in plain view during surgery and the exact same procedure may have been done to both (e.g., breast implants, breast reduction) that does not always guarantee ideal symmetry after surgery.

 One of the main reasons is that most women have some degree of congenital breast asymmetry. It may be very slight and often unnoticed, particularly if the breasts are small, but it is almost always there. When the breasts become enlarged during augmentation, what was once a slight and unnoticeable difference can now become more magnified and apparent…often prompting the thought or statement from the patient…how could this happen? (thus the value of before surgery pictures and the pointing out of any asymmetry in the mounds and nipples beforehand) Mathematical operations such as lifts and reductions will have presurgical markings that are identical in all dimensions and this can certainly improve many pre-existing significant breast asymmetries. But the healing process rarely responds in a predictable measurable way. The amount of bruising, fluid collections and tissue reactions at the suture lines all control how the mound will end up being shaped and the scars will look.

These breast surgery considerations brings me to the concept of ‘sister surgery’, which is well known amongst plastic surgeons. This is the reality that perfect breast symmetry should not be expected after any breast reshaping surgery. They may look somewhat similar, like sisters, but they are not going to be identical twins when all healing is done. This may seem to set the bar for expectations as fairly low, but it is an unavoidable reality. I certainly have seen numerous breast surgeries that looked about close to ideal as possible but this is more uncommon than common.

The sister concept most certainly is evident right after surgery and during the weeks to months that follow as they heal. They never look the same even if it is as straightforward as just the placement of breast implants. This is why one shouldn’t be too critical right after surgery. It will take up to three months, regardless of the breast procedure performed, to make a final judgment as to the shape and symmetry between the breasts. This is why revisional breast surgery should wait at least three months after surgery before doing a critical comparison of the two sisters.

Dr. Barry Eppley

 Indianapolis, Indiana

The sagging breast is the most formidable challenge in aesthetic plastic surgery of the breast. Not only because the scars needed for breast lifting create new aesthetic concerns but the sustainability of the lifted breast is not assured. While many women want their breast lifted, they are often understandably averse to the scars. But real breast lifting requires scars and they are an unavoidable trade-off for significant breast reshaping.

There are numerous methods for breast lifting or mastopexy and they all share two fundamental concepts; nipple elevation and an underlying pattern of skin removal and tightening. The skin reduction pattern is the most recognizeable aspect of a breast lift because of the scars that are left in its wake. Historically, the inverted-T scar pattern was the most common approach but more scar-sparing techniques have evolved in efforts to limit the size of the scar. This has led to vertical (lollipop) and periareolar (donut) breast lift designs. These work well when the degree of breast sagging is not severe. But severe sagging cases still require more extensive scars.

Innovations in breast lift surgery are needed as the perfect breast lift operation does not yet exist. In that spirit, a new glandular Z-breast lift technique was recently reported in the July 2011 online issue of Eplasty, This breast lifting technique borrows from the well known z-plasty technique used in contracture releases and scar revision. Using a fixed geometric pattern, the glandular breast tissue is lifted and reoriented. It was first tested in 15 female cadavers where it was learned that it could be completed in less than one hour per breast and the nipple moved upward an average of over 5 cms. By planning the inferior flap of the z-plasty to include the nipple, a natural superomedial pedicle is created and with transposition acts as internal support for the rotated nipple. How the excess breast skin is managed is still done completely independent of the glandular z-plasty. The skin is addressed by any of the standard designs whether it be periareolar, vertical or inverted-T.

This innovative breast lifting technique is both novel and interesting. It does appear to offer an improved method for nipple elevation and support. Making the sustainability of the lift based on the glandular tissue is likely to be more effective than relying on skin support alone. But from a patient’s perspective, it offers  no real advances in limiting scarring which is always the patient’s main concern. Perhaps having better gland support for some patients may decrease the need for external skin tightening. Until I use this technique or see a clinical report with its use, its benefits for breast lifting remain theoretical.

Dr. Barry Eppley

Indianapolis, Indiana

Background: A woman’s breast is not a stable structure over her lifetime. It is exposed to many changes from its initial development throughout puberty to an older woman. Undoubtably the greatest changer of breast shape is pregnancy, causing gradual expansion and then a relatively rapid deflation. With this overall yoyo of breast shape comes loss of breast tissue and stretching of the skin as a consequence. When the process is repeated more than once, the loss of breast shape and position on the chest wall is inevitable.

Sagging of the breast (ptosis) and loss of volume (involution) has many women seeking breast reshaping plastic surgery. For some women, the simple placement of an implant not only restores volume but provides just enough of a lift that this is the only corrective procedure they need. This can be foretold before surgery by the location of the nipple. If it is above the lower breast fold, then no concomitant lifting procedure will be needed. These are the fortunate of breast reshaping patients.

When the nipple is at or below the lower breast fold, an implant alone is not going to be enough to restore an aesthetically pleasing position of the nipple on the breast mound. Implants simply do not create any substantial breast lifting effect, no matter what a patient hopes or has read. When this degree of breast ptosis exists, the need for a lift with an implant can not be avoided. While some patients do not desire a lift, they may elect to have an implant placed first to prove whether a lift is really ultimately needed. I am not opposed to this approach as long as patients do not confuse hope for oversight on my part afterwards.

Breast lifts come in a variety of types, differentiated only by the amount of scar they create and how much breast mound lifting is achieved and the nipple position is moved upward. To no surprise, there is a fairly direct correlation between the amount of scarring and the amount of overall breast lifting. The more scar that is created on the bottom of the breast below the nipple, the more lifting that is achieved.

Case Study: This 25 year-old Hispanic female wanted to improve her breast shape and size after having two children. She had lost much of her breast volume and developed a Grade III ptosis in both breasts. (nipple at or just below the lower breast fold) In discussing a combination implant and lifting procedure, the concerns about scarring were stressed. This is of particular relevance in patients with increasing skin pigmentation. As skin pigment increases, the more the scar may be noticeable or develop some hyperpigmentation after surgery.

Under general anesthesia, she had 500cc saline implants placed in a partial submuscular dual plane position. She also had a full vertical breast lift with resulting vertical scars down to the fold and some horizontal extension of the scars along the fold as well.

Her postoperative course was typical in that the implants initially were high early after surgery. But with the resolution of the swelling and some skin relaxation, the implants settled into the desired position. This settling resulted in some loss of upper pole fullness which she had really liked in the early period after surgery. While she has not complaind about the scars, I do not personally like them even though I would consider them typical for her skin pigmentation.

Now that it is one year after surgery, she is going to have a revision. She is debating whether to just add more volume to her existing implants or place new larger implants to get back some more upper pole fullness. This is a financial decision. At the same time I will revise her vertical breast scars as I think they can turn out better. (more narrow)

Case Highlights:

· Reshaping of the deflated and sagging breast requires a combination of implant volume addition and nipple lifting and skin tightening manuevers.

· Scars are an inevitable consequence of the breast lift part of the procedure and must be considered an aesthetic trade-off of the combination breast reshaping procedure.

· Breast reshaping through a combination lift and implant placement is one of the hardest body contouring procedures to perform and the need for revision for optimal results is common.

Dr. Barry Eppley

Indianapolis, Indiana